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Curs 8 RBOT:

RECUPERAREA POST-
TRAUMATICA A GENUNCHIULUI

Dr. Florin Filip


ffilip_99@yahoo.com
FEFS/ DSDU
An universitar 2017/ 2018
Anatomie functionala (1)
- Genunchiul este o articulatie majora expusa la multiple
traumatisme directe/ indirecte
- Slaba acoperire cu tesuturi moi (plagi!)
- Implicata in biomecanica statica/ dinamica a membrului
inferior:
- asigurarea statica in momentul de sprijin
- asigurarea pozitiei piciorului in momentul balansului  adaptarea la
denivelarile terenului
- Poate suferi in caz de imobilizare pentru alte afectiuni
ortopedice
- Functia articulara si integritatea muscularturii prorpii sunt
strans legate
• Complex joint that endures great amounts
of trauma due to extreme amounts of
stress that are regularly applied
• Hinge joint w/ a rotational component
• Stability is due primarily to ligaments, joint
capsule and muscles surrounding the joint
• Designed for stability w/ weight bearing
and mobility in locomotion
Anatomia genunchiului (1)
Anatomia genunchiului (2)
Anatomia genunchiului (3)
Anatomia genunchiului (4)
Anatomia genunchiului (5)
Anatomia genunchiului (6)
Anatomia genunchiului (7)
Biomecanica genunchiului (1)

- Flexia genunchiului :
- ROM normal intre 130-1400
– ADL necesita flexie de 115°
– Poate creste pana la 160° in ‘squatting’

- Extensia: 5-100 , hiperextensia este considerata normala


- Articulatia patelo- femurala (PFJ):
- Creste performanata mecanica a grupului qvadriceps (Q)
- Diminua frecarea la nivelului Q si al condililor femurali
- Ditribuie uniform presiunile de la nivel femural
Biomecanica genunchiului (2)

Activities Knee Flexion


• normal gait/level 60°
surfaces
• stair climbing 80°
• sitting/rising from 90°
most chairs
• sitting/rising from 115º
toilet seat
• advanced function > 115°
Biomecanica genunchiului (3)
Etiopatogenia traumatismelor genunchiului
- Leziunile traumatice sunt relativ frecvente (articulatie
superficiala, expusa agentilor din mediu)
- Slaba acoperire cutanata explica incidenta mare a fracturilor
deschise
- Stabilitatea genunchiului depinde de numerosi factori
musculo- ligamentari, astfel incat se intalnesc leziuni
particulare (menisc, LIA, etc.)
- Forme clinice: fracturi, entorse, luxatii, leziuni vasculo-
nervoase
- Forme particulare:
- fracturi de platou tibial sau diafiza femurala
- rupturi de ligamente incrucisate sau colateraler
- fracturi de rotula sau rupturi de tendon rotulian
Principii de tratament KT
- Sechelele traumatice sunt reprezentate de:
- Durere
- Deficit de stabilitate
- Deficit de mobilitate
- Combaterea durerii este primordiala deoarece:
- Determina atitudini vicioase (flexum)
- Impiedica ortostatismul si mersul
- Dupa obtinerea unui genunchi indolor se vor recupera
stabilitatea si mobilitatea (!se va evita mobilizarea precoce)
- Se vor utiliza si tehnici preliminare kinetoterapiei propriu-
zise (posturare, combaterea edemului, troficitate, etc.)
- Reluarea mersului este etapa finala a programului de
recuperare
Tratamentul durerii
- Etiopatogenia:
- Cauze osoase (hiperemia de staza- Trueta)
- Cauze articulare (cresterea presiunii intraarticulare)
- Cauze periarticulare (edem posttraumatic, hematom muscular, leziuni
periost)
- Solutii terapeutice:
- Repaus la pat, deplasare cu sprijin (carje, cadru, baston)
- Medicatie antiinflamatorie, antalgica si sedativa
- Infiltratii cu hidrocortizon si xilina
- Electroterapie antalgica (diadinamice, curenti Trabert, medie-
frecventa)
- Termoterapie (parafina, solux, US)
- KT fara incarcare, masaj, diapulse
- Tractiune continua si tratament antidecliv, atele gipsate
Clinica traumatismelor genunchiului (2)
Clinica traumatismelor genunchiului (1)
Clinica traumatismelor genunchiului (4)
Clinica traumatismelor genunchiului (3)
Clinica traumatismelor genunchiului (5)
Clinica traumatismelor genunchiului (6)
Mobilitate- stretching
Mobilitate- strengthening
Proprioceptia
Terapia ocupationala
Terapia ocupationala
Evolutia procesului de recuperare
Fazele vindecarii post- traumatice

INFLAMMATORY FIBROBLASTIC REMODELING

TISSUE Inflammation (pain, Granulation tissue Collagen fibers


redness, swelling, Collagen synthesis thicken
RESPONSE temp) Inc tissue strength
PAIN ONSET BEFORE resistance WITH resistance AFTER resistance

REHAB PHASE Protection Controlled Motion Return to Function

REHAB GOALS Control inflammation Promote mobile scar Inc strength and
Promote early healing Inc pain free motion endurance
Prevent immob effects Begin strengthening Progress to full
function
REHAB Pain management Pain management Stretch progressions
GUIDELINES ROM ROM / Stretching Dynamic PREs
Isometrics Light PREs Proprioception
Early proprioception Endurance, Power,
and Skilled Activities
Rehabilitation Techniques
• Phase I:
– Control pain, swelling and assist tissue
healing
• P.R.I.C.E.
– For some knee injuries may require immobilizer or
rehabilitation brace
• Modalities
– Maintain core and cardiorespiratory function
Rehabilitation Techniques

• Phase II: ROM


– Early ROM can minimize harmful changes
in ligaments due to immobilization
• AROM: Heel slides, active hamstring stretch,
squats, quad sets
• PROM: Prone/supine leg extensions with or
w/o assistance. Static quad, hip, groin, glut,
ITB, seated calf and hamstring stretching
• AAROM: Wall Slides, heel slides with
contralateral limb assistance
• PNF
Rehabilitation Techniques
• Phase III: Strengthening.
– Overload principle, but not too early or too
aggressive
• can harm healing tissue
• Gently progressive: isometric to isotonic to
isokinetic to plyometric to functional activity
• Closed chain exercises proven to be more
effective for knee rehabilitation
– Can implement early on in most knee rehabs
– OKC can increase anterior tibial shear
Rehabilitation Techniques

• Isometrics: Quad Sets, Glut Sets, Hamstring


Sets. Co-contraction
• Isotonic: SLR-hip flex, ext. abduction and
adduction. Squats; DL & SL, lunges; single,
multiplane, step ups forward and lateral.
Deadlifts; double leg and single leg. Clams
• Proprioception: Progressive balance
exercises
• Can add unstable surfaces, perturbations, ball
toss and/or rotation to exercises as they progress
Rehabilitation Techniques
• Phase IV: Functional progressions return
to sport activity
– Running progression: straight ahead at ½
speed to ¾ speed to full sprint to change of
direction lateral movement @ ½ speed to ¾
speed to full speed.
– Sport specific movements and activity
Rehabilitation Techniques

• Phase V: Maintenance and monitoring


of return to sport

• All phases should include core and


cardiorespiratory exercises
• Athlete should be comfortable and
confident in their progression
• Use pain and swelling as guide for
progression.
Recognition and Management of
Specific Injuries
• Medial Collateral Ligament Sprain
– Cause of Injury
• Result of severe blow or outward twist – valgus
force
– Signs of Injury - Grade I
• Little fiber tearing or stretching
• Stable valgus test
• Little or no joint effusion
• Some joint stiffness and point tenderness on lateral
aspect
• Relatively normal ROM
• MCL
– Grade 1
• Can begin early ROM and isometric exercise 1-
2 days after injury
• May return to activity fairly quickly
– Grade 2
• May require 4-5 days of rest to allow
inflammation to subside before starting rehab
ex.
• 4-6 week recovery period

– Exercise bike and closed chain exercises can begin


for grade 1 & 2 sprains as early as it is tolerated
• MCL
– Grade 3 sprains
• May take up to 3 months to return
• Brace for 4-6 weeks, non-weight bearing for 3
weeks.
– Can remove brace for treatment and rehab
– Rehab limited to isometrics and straight leg
exercises
– After the brace is discontinued can progress rehab
similar to Grade 1 & 2 sprains
• Functional and
Prophylactic Knee
Braces
– Used to prevent and
reduce severity of knee
injuries
– Provide degree of
support to unstable knee
– Can be custom molded
and designed to control
rotational forces and
tibial translation
Pain Management
• PRICE (Protection, Rest, Ice, Compression, Elevation)
• Moist heat (If not in inflammatory)
• Physical Agents – ionto, e-stim, TENS
• Joint mobilization – Grades I and II
Motion
• PROM
– Patellar mobs
– Tibialfemoral Joint mobilization (accessory and physiologic
motions)
• Grade III-V
• Flex/Ext (some IR and ER)
– Stationary bike
– Fibular mobs
• AAROM
• AROM
– Heel slides
Strengthening
• Isometric
– Quad sets
– Hamstring sets
– Glut Sets
– ABD ISO
• Dynamic
– Open chain
– Closed chain
Strengthening

• Open Chain
– SLR
– Steamboats
– Short arc quads
– Knee extensions (avoid last 30 deg)
– Hamstring curls
Strengthening
• Closed Chain
– Terminal knee extension
– Squat progression (wall, mini, full)
– Lunges / Split squats
– Step-ups/Step-downs
– Hamstring stool scoots
– Eccentric HS in kneeling (difficult can be painful)
– Calf raises
Strengthening
• Do not forget the Hip
• Prior emphasis on quad/VMO activation and
deficits missed weakness and imbalance of hip
ER, ABD and EXT
Proprioception
• SLS
– Eyes open / closed
• Foam
• BOSU Ball
• Rebounder
• BAPS Board
• Body Blade
• Clock Drills
• Perturbations
Endurance
• Bike
• Treadmill
– Walk, Jog, Run
• Elliptical
• Stair stepper
• Pool
– Swim, Jog, Aerobics
Power
• Advanced weight lifting
– Leg press
– Hamstring curl
– Squats
– Lunges
– Dead lifts
– Calf raises
Skilled Activity
• Figure 8s
• Kariokas
• Single leg hop
• Lateral shuffles
• Ladder drills
• Form drills
• Box jumps/plyometrics
Full Activity
• Walk to run progression
• Return to sport drills
• Return to full practice
• Return to competition
Summary
• Effective interventions:
– Eccentric exercise
– General quad strengthening
– Hip, trunk, ankle strengthening: emphasize form
– Plyometrics
• Consider:
– Taping during exercise if reduces pain
– Foot orthoses if rearfoot varus
– SI joint manipulation if fits hypothesized criteria